One of the most important things you can do for your health is to schedule regular checkups with your Primary Care Provider (PCP).
Use these preventive care guidelines to help keep you and your family on the road to good health. Bring the schedules to your next checkup or office visit, and discuss them with your physician.
Frequently Asked Questions
What are the health maintenance guidelines?
The guidelines list the types of care screenings and exams needed for your particular age and gender.
- For infants and young children, the guidelines focus on physical and mental development, immunizations, nutrition, and safety.
- For children and young adults, the focus is on maintaining or developing healthy lifestyle habits and eliminating high-risk behaviors.
- For adults, the focus continues to be on eliminating high-risk behaviors, however, screening for chronic and/or life-threatening disease becomes more important.
Does my health insurance cover these preventive care exams?
The health care reform Affordable Care Act (ACA) requires that plans begin providing benefits for preventive services with no member cost share, such as copayments, deductibles, and coinsurance, when services are performed by in-network providers. However, some plans are not required to comply with this mandate.
If your contract is affected by this change, Wellmark will provide first-dollar coverage for covered preventive services performed by in-network providers. Claims for preventive services from out-of-network providers will process using the benefits specified in your benefits policy or coverage manual, and will continue to apply member cost-sharing amounts.
The change will become effective in stages over the next several months, depending on your health plan. For more details about your preventive benefits, contact Customer Service at the number on your identification card.
What is a health maintenance exam (HME)?
A health maintenance exam is what was commonly known as a "routine" or "annual" physical. You might have heard to have an "annual physical". Your health benefits, however, do not necessarily cover "annual" physicals. Instead, your benefits cover periodic health maintenance exams.
How is the frequency of health maintenance exams determined?
Our guidelines are based on recommendations from the American Academy of Pediatrics, The American Academy of Family Practice, the American College of Obstetrics and Gynecology, and the Center for Disease Control, among others.
Wellmark's guidelines are reviewed annually. We provide benefits for health maintenance exams at timeframes that are considered most appropriate given your age and gender.
What is the difference between a health maintenance exam and a well-female exam?
A health maintenance exam is a complete physical, including:
- Health history
- A review of all health and lifestyle risk factors
- An exam of all systems including cardiovascular, respiratory, neurological, musculoskeletal, reproductive and behavioral
- Laboratory studies appropriate for age, risk and sex
- Discussion of recommended lifestyle changes.
These exams are recommended every five years from ages 18-39, every 2-3 years from ages 40-49, and every 1-2 years for ages 50 and over.
Well-female exams are far less extensive, limited essentially to pelvic and Pap tests, as well as your clinical breast exam. Well-female exams can be performed by your primary care provider or selected Plan OB/GYN provider.
How often should I have a well-female exam?
Well-female exams are recommended for women 18 and over. Sexually active women should have well-female exams every 1-3 years. Discuss the interval that's appropriate for you with your physician.
What if my child has already had his or her health maintenance exam this year, but is now required to have a sports physical for school?
Since your child already had a health maintenance exam, it is usually not necessary to also have a separate sports physical. In this case, have your provider complete the school's physical form, and use the date of the previous physical examination. This should be acceptable documentation for the school's purposes.
If there is a range recommended for an exam, how often should I schedule the exam?
Where there is a range, such as 1-2 years, talk to your physician about how often you need to have the exam.
What if my provider recommends that I have these exams more frequently?
In most cases, your benefits provide coverage for an exam to be performed once per benefit period.
If the reason for a more frequent exam schedule is due to an underlying chronic disease, benefits would apply. However, if your physician just wants you to have health maintenance exams at a more frequent rate than once per benefit period, the additional exams are not a covered benefit.